Beaufort Jasper EOC Head Start

Parent Request for Records

I, wish to request records for the following student.

Student Name:*

Date of Birth:*

Center:*

I am requesting the following records:

Assessment Reports

Attendance

Birth Certificate

Immunizations

Test Scores

Other:

Last date/year attended:*

I understand I will be contacted by phone call as to when I may return to pick up these records.
My phone number is .

I do hereby acknowledge that I have a legal right to request and receive these records. I understand that I am required to provide a valid photo I.D. I understand that if I am not the birth parent I must provide current and valid proof of custody for the child for whom I am requesting records. I understand that I will be required to sign for all records once they are copied and presented to me. I understand that a request records will be processed within five business days of receipt.

I confirm that I have read and understand this form. *

By checking this option, I choose to manually sign this form.

By checking this option, I prefer to have the system electronically sign this form for me.

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Parent Signature

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